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Calibrating urgency: triage decision-making in a pediatric emergency department

Advances in Health Sciences Education volume 13, pages 503–520 (2008)Cite this article

Abstract

Triage, the first step in the assessment of emergency department patients, occurs in a highly dynamic environment that functions under constraints of time, physical space, and patient needs that may exceed available resources. Through triage, patients are placed into one of a limited number of categories using a subset of diagnostic information. To facilitate this task and standardize the triage decision process, triage guidelines have been implemented. However, these protocols are interpreted differently by highly experienced (expert) nurses and less experienced (novice) nurses. This study investigates the process of triage; the factors that influence triage decision-making, and how the guidelines are used in the process. Using observations and semi-structured interviews of triage nurses, data was collected in the pediatric emergency department of a large Canadian teaching hospital. Results show that in emergency situations (1) triage decisions were often non-analytic and based on intuition, particularly with increasing expertise, and (2) guidelines were used differently by nurses during the triage process. These results suggest that explicit guideline information becomes internalized and implicitly used in emergency triage practice as nurses gain experience. Implications of these results for nursing education and training, and guideline development for emergency care are discussed.

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References

  • Andersson, A. K., Omberg, M., & Svedlund, M. (2006). Triage in the emergency department—a qualitative study of the factors which nurses consider when making decisions. Nursing in Critical Care, 11(3), 136–145.

    Article  Google Scholar 

  • Barak, N., Margolis, C. Z., & Gottlieb, L. K. (1998). Text-to-algorithm conversion to facilitate comparison of competing clinical guidelines. Medical Decision Making, 18(3), 304–310.

    Article  Google Scholar 

  • Baxter P., & Rideout E. (2006). Second-year baccalaureate nursing Students’ decision making in the clinical setting. Journal of Nursing Education, 45(4), 121–127.

    Google Scholar 

  • Benner, P. (1984). The Dreyfus model of skill acquisition applied to nursing. In P. Benner (Ed.), From novice to expert: Excellence and power in clinical nursing practice (pp. 13–38). Menlo Park: Addison-Wesley.

    Google Scholar 

  • Benner, P. (2004). Using the dreyfus model of skill acquisition to describe and interpret skill acquisition and clinical judgment in nursing practice and education. Bulletin of Science, Technology & Society, 24(3), 188–199.

    Article  Google Scholar 

  • Benner, P., & Tanner, C. (1987). Clinical judgment: How expert nurses use intuition. American Journal of Nursing, 87(1), 23–31.

    Article  Google Scholar 

  • Beveridge R. (1998). CAEP issues. The Canadian triage and acuity scale: A new and critical element in health care reform. Canadian association of emergency physicians. Journal of Emergency Medicine, 16(3), 507–511.

    Article  Google Scholar 

  • Beveridge, R., Ducharme, J., Janes, L., Beaulieu, S., & Walter S. (1999). Reliability of the Canadian emergency department triage and acuity scale: interrater agreement. Annals of Emergency Medicine, 34(2), 155–159.

    Article  Google Scholar 

  • Boshuizen, H. P. A., & Schmidt, H. G. (1992). On the role of biomedical knowledge in clinical reasoning by experts, intermediates, and novices. Cognitive Science, 16(2), 153–184.

    Article  Google Scholar 

  • Buchman, T. G., Patel, V. L., Dushoff, J., Ehrlich, P. R., Feldman, M., Levin, B., Miller, D. T., Rozin, P, Levin, S. A., & Fitzpatrick, S. (2006). Enhancing the use of clinical guidelines: A social norms perspective. Journal of the American College of Surgeons, 201, 826–836.

    Google Scholar 

  • Buesching, D. P., Jablonowski, A., Vesta, E., Dilts, W., Runge, C., Lund, J., & Porter, R. (1985). Inappropriate emergency department visits. Annals of Emergency Medicine, 14(7), 672–676.

    Article  Google Scholar 

  • Candela, L., Dalley, K., & Benzel-Lindley, J. (2006). A case for learning-centered curricula. Journal of Nursing Education, 45(2), 59–66.

    Google Scholar 

  • Cioffi, J. (1998). Decision making by emergency nurses in triage assessments. Accident & Emergency Nursing, 6(4), 184–191.

    Article  Google Scholar 

  • Cioffi, J., Purcal, N., & Arundell, F. (2005). A pilot study to investigate the effect of a simulation strategy on the clinical decision making of midwifery students. Journal of Nursing Education, 44(3), 131–134.

    Google Scholar 

  • Choudhry, N. K., Fletcher, R. H., & Soumerai, S. B. (2005). Systematic review: The relationship between clinical experience and quality of health care. Annals of Internal Medicine, 142(4), 260–273.

    Google Scholar 

  • Cone, K. J., & Murray, R. (2002). Characteristics, insights, decision making, and preparation of ED triage nurses. Journal of Emergency Nursing, 28(5), 401–406.

    Article  Google Scholar 

  • Cooper, R. J., Schriger, D. L., Flaherty, H. L., Lin, E. J., & Hubbell, K. A. (2002). Effect of vital signs on triage decisions. Annals of Emergency Medicine, 39(3), 223–232.

    Article  Google Scholar 

  • Dong, S. L., Bullard, M. J., Meurer, D. P., Colman, I., Blitz, S., Holroyd, B. R., & Rowe, B. H. (2005). Emergency triage: Comparing a novel computer triage program with standard triage. Academic Emergency Medicine, 12(6), 502–507.

    Article  Google Scholar 

  • Edwards, B. (1994). Telephone triage: How experienced nurses reach decisions. Journal of Advanced Nursing, 19(4), 717–724.

    Article  Google Scholar 

  • Ferrario, C. G. (2003). Experienced and less-experienced nurses’ diagnostic reasoning: implications for fostering students’ critical thinking. International Journal of Nursing Terminologies & Classifications, 14(2), 41–52.

    Article  Google Scholar 

  • Fonteyn, M. E., Grobe, S. J., & Kuipers, B. J. (1991). A descriptive analysis of expert critical care nurses’ clinical reasoning. In E. J. S Hovenga, K. J. Hannah, K. A. McCormick, & J. S. Ronald (Eds.), Nursing informatics ’91 (pp. 765–768). Melbourne, Australia: Springer Verlag.

    Google Scholar 

  • Gerdtz, M. F., & Bucknall, T. K. (2001). Triage nurses’ clinical decision making. An observational study of urgency assessment. Journal of Advanced Nursing, 35(4), 550–561.

    Article  Google Scholar 

  • Hampers, L. C., & McNulty, J. E. (2002). Professional interpreters and bilingual physicians in a pediatric emergency department: Effect on resource utilization. Archives of Pediatrics & Adolescent Medicine, 156(11), 1108–1113.

    Google Scholar 

  • Hannah, V. (2006). The big picture: Learning to think like a nurse. Journal of Nursing Education, 45(6), 239–240.

    Google Scholar 

  • Higgins, M. P., & Tully, M. P. (2005). Hospital doctors and their schemas about appropriate prescribing. Medical Education, 39, 184–189.

    Article  Google Scholar 

  • Katz, D. A. (1999). Barriers between guidelines and improved patient care: An analysis of AHCPR’s Unstable Angina Clinical Practice Guideline. Agency for Health Care Policy and Research. Health Services Research, 34(1 Pt 2), 377–389.

    Google Scholar 

  • Kenny, C. (1994). Nursing intuition: can it be researched? British Journal of Nursing, 3(22), 1191–1195.

    Google Scholar 

  • Leprohon, J., & Patel, V. L. (1995). Decision-making strategies for telephone triage in emergency medical services. Medical Decision Making, 15(3), 240–253.

    Article  Google Scholar 

  • Lyneham, J. (1998). The process of decision-making by emergency nurses. Australian Journal of Advanced Nursing, 16(2), 7–14.

    Google Scholar 

  • Marsden, J. (1998). Decision-making in A&E by expert nurses. Nursing Times, 94(41), 62–65.

    Google Scholar 

  • Maudsley G., & Strivens J. (2000). Promoting professional knowledge, experiential learning and critical thinking for medical students. Medical Education, 34(7), 535–544.

    Article  Google Scholar 

  • Mor, M., &Waisman (2002). Triage principles in multiple casualty situations involving children—The Israeli experience. Retrieved on January 14, 2006 from www. pem-database.org.

  • Murray, M. J., Bullard, M. J., & Grafstein, E. (2004). Revisions to the Canadian emergency department triage and acuity scale implementation guidelines. Canadian Journal of Emergency Medicine, 6, 421–427.

    Google Scholar 

  • Oermann, M. H. (1997). Evaluating critical thinking in clinical practice. Nurse Educator, 22(5), 25–28.

    Article  Google Scholar 

  • Patel, V. L., Arocha, J. F., Diermeier, M., Greenes, R. A., & Shortliffe, E. H. (2001a). Methods of cognitive analysis to support the design and evaluation of biomedical systems: The case of clinical practice guidelines. Journal of Biomedical Informatics, 34, 52–66.

    Article  Google Scholar 

  • Patel, V. L., Arocha, J. F., Diemeier, M., How, J., & Mottur-Pilson, C. (2001b). Cognitive psychological studies of representation and use of clinical practice guidelines. International Journal of Medical Informatics, 63(3), 147–168.

    Article  Google Scholar 

  • Patel, V. L., Arocha, J. F., & Kaufman, D. R. (1994). Diagnostic reasoning and expertise. The Psychology of Learning and Motivation: Advances in Research and Theory, 31, 137–252.

    Google Scholar 

  • Patel, V. L., Arocha, J., & Lecissi, M. (2001c). Impact of undergraduate medical training on housestaff problem solving performance, implications for health education in problem-based curricula. Journal of Dental Education, 65(11), 1199–1218.

    Google Scholar 

  • Patel, V. L., & Currie, L. M. (2005). Clinical cognition and biomedical informatics: issues of patient safety. International Journal of Medical Informatics, 74(11–12), 869–885.

    Google Scholar 

  • Patel, V. L., & Groen, G. J. (1986) Knowledge-based solution strategies in medical reasoning. Cognitive Science, 10, 91–116.

    Article  Google Scholar 

  • Patel, V. L., Kaufman, D. R, & Arocha, J. F. (2002). Emerging paradigms of cognition and medical decision making. Journal of Biomedical Informatics, 35, 52–75.

    Article  Google Scholar 

  • Patel, V. L., Kaufman, D. R. & Magder, S. A. (1996). The acquisition of medical expertise in complex dynamic environments. In K. A. Ericsson (Ed.), The road to excellence: the acquisition of expert performance in the arts and sciences, sports, and games (p. xi, 369). Mahwah: Lawrence Erlbaum Associates.

  • Pearson, S. D., Goldman, L., Garcia, T. B., Cook, E. F., & Lee, T. H. (1994). Physician response to a prediction rule for the triage of emergency department patients with chest pain. Journal of General Internal Medicine, 9(5), 241–247.

    Article  Google Scholar 

  • Poole, S. R., Schmitt, B. D., Carruth, T., Peterson-Smith, A., & Slusarski, M. (1993). After-hours telephone coverage: the application of an area-wide telephone triage and advice system for pediatric practices. Pediatrics, 92(5), 670–679.

    Google Scholar 

  • Roberts J. D., While A. E., & Fitzpatrick, J. M. (1993). Problem solving in nursing practice: Application, process, skill acquisition and measurement. Journal of Advanced Nursing, 18(6), 886–891.

    Article  Google Scholar 

  • Shesser, R., Kirsch, T., Smith, J., & Hirsch, R. (1991). An analysis of emergency department use by patients with minor illness. Annals of Emergency Medicine, 20(7), 743–748.

    Article  Google Scholar 

  • Simmons, B., Lanuza, D., Fonteyn, M., Hicks, F., & Holm, K. (2003). Clinical Reasoning in Experienced Nurses. Western Journal of Nursing Research, 25(6), 701–719.

    Article  Google Scholar 

  • Simpson, E., & Courtney, M. (2002). Critical thinking in nursing education: Literature review. International Journal of Nursing Practice, 8, 89–90.

    Article  Google Scholar 

  • Strauss, A., & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for developing grounded theory, 2nd edn. Thousand Oaks, CA: Sage Publications.

    Google Scholar 

  • Travers, D. A., Waller, A. E., Bowling, J. M., Flowers, D., & Tintinalli, J. (2002). Five-level triage system more effective than three-level in tertiary emergency department. Journal of Emergency Nursing, 28(5), 395–400.

    Article  Google Scholar 

  • Ward A., & Gracey J. (2006). Reflective practice in physiotherapy curricula: A survey of UK university based professional practice coordinators. Medical Teacher, 28, 32–39.

    Article  Google Scholar 

  • Washington, D. L., Stevens C. D., Shekelle, P. G., Baker, D. W., Fink, A., & Brook, R. H (2000). Safely directing patients to appropriate levels of care: guideline-driven triage in the emergency service. Annals of Emergency Medicine, 36(1), 15–22.

    Article  Google Scholar 

  • Williams, R. M. (1996). Triage and emergency department services. Annals of Emergency Medicine, 27(4), 506–508.

    Article  Google Scholar 

  • Zimmermann, P. G. (2001). The case for a universal, valid, reliable 5-tier triage acuity scale for US emergency departments. Journal of Emergency Nursing, 27(3), 246–254.

    Article  Google Scholar 

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Acknowledgments

The research reported in this paper was supported by a grant from the Medical Research Council of Canada to Vimla Patel (MRC-MA-13439) and in part through the Department of Biomedical Informatics at Columbia University, New York. We would like to thank the participants in this study, and the nursing staff of the Emergency Department at McGill University, Montreal who made this study possible. We also wish to acknowledge David Kaufman and Laurie Barkun for their assistance with data collection and the development of the interview guide; and Eneida Mendoca and Elizabeth Nehemiah for their comments during the revision process.

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  1. Laboratory of Decision Making and Cognition, Department of Biomedical Informatics, Columbia University Medical Center, VC5 622 West 168th Street, New York, NY, 10032, USA

    Vimla L. Patel, Lily A. Gutnik & Daniel R. Karlin

  2. Division of Pediatric Emergency Medicine, Department of Pediatrics, Columbia University, New York, USA

    Martin Pusic

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  1. Vimla L. Patel
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  2. Lily A. Gutnik
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Correspondence to Vimla L. Patel.

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Patel, V.L., Gutnik, L.A., Karlin, D.R. et al. Calibrating urgency: triage decision-making in a pediatric emergency department. Adv in Health Sci Educ 13, 503–520 (2008). https://doi.org/10.1007/s10459-007-9062-6

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  • DOI: https://doi.org/10.1007/s10459-007-9062-6

Keywords

  • Triage
  • Decision-making
  • Emergency department
  • Nursing education
  • Clinical guidelines